Creating Adequate Projection With Closed Rhinoplasty

The Problem

Creating adequate projection with closed rhinoplasty.

Successful rhinoplasty requires integration of all anatomic components of the nose to achieve desirable form and function. Creating a beautiful nasal tip begins with analysis of its intrinsic and extrinsic characteristics: width, definition, volume, position, rotation, and projection. The last three characteristics, position, rotation, and projection, are intimately related. Inadequate surgical focus upon any one of these three components will diminish the overall appearance of the tip and affect the end result of a rhinoplasty.

Patients requesting rhinoplasty frequently present with convexity of the osseocartilaginous dorsum and an underprojecting nasal tip, either in repose or when smiling. Projection has both extrinsic and intrinsic components. The extrinsic component is measured from the alar crease to the nasal tip (AC–T). The curved line from AC, arcing to T is composed of three segments: infralobular, columellar, and premaxillary. These components should be equal in length. Variation in their length ratio may determine whether the tip is underprojecting or overprojecting. The intrinsic component of projection is measured from the columellar breakpoint to the nasal tip. If the tip droops below the anterior septal angle, then it is underprojected. A drooping nasal tip shadows the upper lip, creating the impression of a shorter upper lip.

The Background

Byrd describes tip projection as a relationship between the distance between the alar crease and the nasal tip (AC–T) compared to the length between the tip and the nasion (N–T). He suggests that AC–T should equal two-thirds of N–T.

Constantian pointed out that tip projection reflects the ability of the alar cartilages to support the tip independently of the height of the nasal dorsum. If the tip hangs from the septal angle, then it is inadequately projecting.

Increased tip projection cannot be rendered adequate by reduction methods alone: the surgeon must use some method of enhancement such as alar cartilage modification, tip grafts, or struts to improve projection.

Multiple maneuvers have been used to achieve improvement to the appearance of the nasal tip. Establishing projection of the nasal tip with adequate tip rotation affects tip position with respect to the nasal dorsum and is a prerequisite to obtaining an excellent result.

Projection-enhancing procedures include the use of suture techniques such as transdomal, medial crural, and medial crural anchor to the anterorcaudal septum. In addition to suture techniques, grafts may be used to enhance the tip (i.e., onlay, shield, subdomal, augmentation of the nasal spine, and maxilla and columellar strut grafts). The Fred technique is a suture technique directed at the base of the nose and uses sutures to move the medial crura anteriorly and thus enhance projection.

When assessing the final result of a rhinoplasty, it is not uncommon to note reasonable projection when comparing the AC–T distance to N–T, but to see persistent rounding of the nasal tip, positioned slightly below the anterior septal angle. There is no discernable supratip breakpoint. This is caused by insufficient rotation and affects the aesthetic result.

The supratip breakpoint is formed by the posterior descent of the septum away from the dorsal line in relation to a subtle convexity of the alar cartilages. The nasal tip must be in anatomical proximity to the anterior septal angle to have a supratip breakpoint. If adequate projection is achieved through a surgical maneuver, but the tip has inadequate rotation, then a supratip breakpoint will not be visible and the tip will still be underprojected.

Cartilage splitting techniques, used to enhance projection, began to receive attention with publication of an article by Goldman in 1957, described vertically splitting the dome. Splitting the dome breaks its curvature and allows for increased vertical support when the split ends are reapproximated. This technique may produce additional projection, but also may produce an undesired result over time in patients with thin skin. The resultant pinched tip has led to disfavor by surgeons for the use of cartilage splitting.

Lipsett introduced a technique in 1959 that called for transection of the lower lateral cartilages medial to the dome. This maneuver preserved the natural curve of the dome and allowed for a degree of rotation. One of the drawbacks of this approach is potential disruption of the infratip lobule related to the position of the split in the middle crura.

For cases requiring a greater degree of rotation with projection, the author currently uses a modification of the Lipsett technique by splitting the medial crura, at least a centimeter below the infralobular segment, but above the footplate. This approach allows for cephalad rotation of the tip without the stigmata of domal or infralobular disruption.

A columellar strut becomes mandatory as a result of disruption of the triangular support of the nasal tip, contributed by the medial crura and footplates. The strut is placed between the medial crura and sutured to the transected segments above and below the transection. Suturing the medial segments to the columellar strut obviates the problems of stiffness and immobility of the tip that can occur with suturing the middle crura or domal cartilages to the septum. Transecting the medial crura, closer to the base of the nose, allows for enhanced tip rotation through its releasing effect. The columella suture complex places support at the base of the nose.

The Indications

The indications for this procedure are for a patient who needs increased projection and rotation of the nasal tip and has a short columella with an acute nasolabial angle.